 For our discussion, basically three issues we'll be focusing on. One, how should the United States government activities in global health be structured to be most effective? I think an enormously important question, too. How can public and political support in the United States or global health initiative best be promoted? And how can the United States partner with others to improve the effectiveness of the global health effort, which I think was discussed a bit at the end of the last panel as well. Then after setting the framework, I'll pose questions to our distinguished panelists. We have an outstanding panel, their resumes are in your materials. I won't repeat them. Let me just mention the names of the people. Senator Gene Shahan, who will be here momentarily, I'm told. Keith Ellison, Congressman from the Twin Cities of Minneapolis. St. Paul. And Tom Pickering, who, as you know, for a long, long time, in one of America's most well-respected, well-regarded diplomats and foreign policy thinkers, I think this country is now entering a period or really has been in a period and is going to continue in this for a long, long time to come of having to make wrenching choices amongst critical priorities because of an unsustainable fiscal situation. In that context, I think the case for a global health initiative is compelling. But if this is going to be achieved, it seems to me that a great deal more is going to have to be done to educate the American people that while this is certainly a moral imperative, it is also enormously in our interest. That discussion would include issues like the spread of infectious disease from countries that don't have public health programs. And it would include our dependence on supply chains to developing countries that can be interrupted through issues around health. Having said that, I can tell you from my own experience when I was a Treasury, when I was Secretary, when we presented similar sorts of points in supporting measures to combat global poverty, the educational effort both with the American people and with Congress were extremely difficult. The Commission's report, as you know, advocates substantially increased funding and also advocates long-term commitments. The Commission also strongly recommends that we seek more effective ways of using the resources that are committed to global health by changes in what is a highly fragmented overlapping and in many ways inefficient structure in our federal government. The Commission recommends there be a deputy director at the NSC to head and coordinate an interagency council. And that would be for planning and for budgets. And that that same council coordinate operational activities. Having said that, in order to avoid bringing operational activities into the White House, the council for those purposes would be chaired by the representatives of the Department of State and from Health and Human Services. But that would still have an overall reporting relationship to the deputy at NSC. Also, in order to provide continuity, the already proposed, the currently proposed $65 billion global health initiative, the President's proposal would be coordinated by the State Department official who would of course would be sitting on this council and ultimately, as I said a moment ago, would be responsible for oversight to the deputy at the NSC. Congress also has a very complicated structure with respect to global health and the Commission proposed that the relevant committees established a joint House Senate consulting group, that this be done on a trial three-year basis for purposes of policy and also for purposes of budgeting. And let me say again, from my own experience of six and a half years, I spent in government, both in the executive branch and on the Hill, the inefficiencies are an immense barrier to effective use of resources. So I think the importance of these recommendations is exceedingly high. Finally, as was discussed a bit in the last panel, the United States has the opportunity to increase its impact on the effectiveness of the global health effort through its work with WHO, UNICEF, the NGOs, other donor countries, private sector donors, and the recipient countries. Two points on partnerships. One, many health issues like infectious disease are transnational and you can only get at that through partnerships. And secondly, there is the spaghetti problem that was mentioned at the end of the last panel and it's interesting when you sit in one of these meetings and see the enormous multiplicity of conditions, forms, processes, requirements. They really can overwhelm recipient countries and enormously reduce the efficiency of assistance. With that, let me begin our panel discussion by posing a question and I guess we'll start with Keith Ellison since Senator Sheen is not here but then when she comes in we'll sort of get her up to speed and let her pitch in. There are those who say that Congress is less effective than it could be. I'm shocked. Absolutely shocked. There may be those who say the contrary but they have a hard time making their case. In your view, can global health break through that environment in Congress and how might that best be pursued? Senator Sheen, let me restate that question because I'll ask both of you. I made the observation that there are those who say that Congress is perhaps somewhat less effective than it could be. This seemed to be a general feeling that might be the case. The audience didn't agree with that. Well, before you came in they did. Now they're a little bit intimidated. So where are you now folks? Now they're a little bit intimidated but the question was, is this an issue that can break through what does seem to be a bit of a mire and some of the partisanship in Congress? Why don't you both respond? We'll start with Senator I suppose. You know, I think it really can and in fact it has. In the past one of the places where in the Senate, and I sit on the Foreign Relations Committee in the Senate, one of the places where there is the most agreement from both sides of the aisle is on foreign policy. And global health is a place where we've got a great record of being bipartisan and how we approach it. And so I think this is a place where it's an opportunity for us to get people to work together because we can see what a difference that good policies when it comes to global health make. I think I agree with the Senator. I think the answer is yes. I think there's some clear challenges but just to confirm the yes. Look, you know, both Democratic and Republican administrations have come forward with foreign assistance in the area of health that have been effective. I mean, PEPFAR was a Bush-era program. MCC was as well and of course there are many other initiatives that have come from the Democratic side. So I think it's something we can get together on. I'll say that there are some distinct challenges. One is foreign assistance reform. I think global health, we should consider it within the context of foreign assistance reform generally. And I also think that it's important that members of Congress make the case to the American people that one, it's a small part of the budget, but two, it's doing good for good sake. We should trust that Americans believe that that is positive. And then we should also make some of the more utilitarian arguments that you made Mr. Rubin, which are that global disease, infectious disease doesn't care about borders. H1N1 was a plane right away and there are many other advantages as well. But I will say that there is a few things that do divide us. And we recently had in the House a conversation convened by Chairman Berman around foreign assistance reform generally. The points of agreement were around issues of global health but then issues of, you know, the issue of family planning and those things. Health issues, to be sure, are still points where we have to work it out. And I'd rather put it up front and deal with it than not. Let me ask a related question. Before you came in, Senator, I made the comment that at least in my view you've got an enormous fiscal problem coming at this country and I think you're going to have to make wrenching, wrenching choices. And I don't think you'd have a choice at some point. In that context, in the context of that debate, which I think has gone for years, how do you think this initiative is likely to fare? Either one of you can... Well, let me tell you, I think that because it is smart, it can fare well if we're all willing to make a few sacrifices. Let's grab the low-hanging fruit first. The fact is that whether you talk to Republicans or Democrats, there is reform in the area of procurement we can do with the Department of Defense that can help ring out savings. We have Soviet-era weapon systems that even generals say that they don't need and we need to look carefully at how we can help the defense of our country remain as effective and agile as it's ever been, but at the same time, look for ways we can save money in outmoded, outdated systems and in the area of procurement in particular. So I think that there's gains to be had. I think that health does have a security component. The healthier people are, hopefully the more stable their societies are, perhaps the more amenable their societies are to our own and there is a component that we need to reflect on, but I think we are going to have to make some tough choices, but I think that there is room to pay for global health and it will pay for itself. Oh, absolutely. Bob, I think you were totally right in pointing out the fact that we're going to quickly going to have to move from stimulus to debt repayment and that there are huge problems out there. The administration has taken a view, which I fully support, that 2011 is a turning year for Iraq, that 2011 also will begin some build-down in Afghanistan. Look, we don't know whether that's going to work, but the determination is there. If we look at the ongoing wartime expenses, I think annually they run between $200 and $400 billion. If we took the goals of this report, 10 to 15 now and 25 later, that would be a very small percentage, and if in fact we could agree that 10 to 15 percent goes into these kinds of programs and the rest goes for debt retirement, we'd be making some progress. We recognize how big the debt is and how long it's going to take to come down, but I don't think it's an impossibility. Admittedly, there are big uncertainties about whether we can save the operational costs of war, but at least they're palpably possible, if I put it that way, and we ought to give that some very serious consideration to go down. This in my view for all the reasons you said is very high priority. We are vulnerable at home. We have high potential to lose markets and economic efficiency, and we have a moral obligation as the world's richest and best cared for country, despite all of the problems of healthcare legislation, and hopefully we'll have that well behind us when we address these questions, that it makes good sense for us to move on in this direction. Let me add to that. I think the report focuses on a couple of things that allow us to spend our dollars very wisely. One is on prevention. The other is on looking at women and children. We know that when we make investments in kids that it makes a huge impact later on, and the point that you made, Ambassador, about it being a whole lot cheaper to spend dollars on global health than on war as a way to provide for national security is a very important one. Former President Clinton and Bill Gates come before the Foreign Relations Committee in the last week or so. And one of the points that President Clinton made, he talked about going into Tanzania into a little village to announce a health initiative and said that this was a village of a couple hundred people and 2,000 people showed up. And he said, you know, when you're out there trying to save the children of parents, they're a whole lot less likely to want to go shooting at you. And this is a way to spend our foreign policy dollars that is going to be very effective. And there are going to be fights about what we do about our debt reduction. There's no doubt about that, and this is going to be a tough argument. But we need to focus on the effectiveness argument, on the results argument, and can we do it better? Yes, I think you're right, Keith. We can make the procurement more effective, and we ought to do that. But we also ought to be able to use the argument that is made in this report that this is a way to effectively use America's soft power around the world. Could I ask you a question, Senator? When you're running for office and somebody criticizes you for wanting to cut defense in order to do something like global health, can you make this case in a way that people will understand that this is really exactly what you just said, or Tom said, I guess, a more effective national security use than the other might be? Well, I think that's the way we have to frame it, is how do we most effectively use our dollars. I think we have to explain it to them, and we have to do a better job than we've done communicating with people in the past. We haven't, you know, as you said, Keith, Americans tend to be very magnanimous and want to be helpful around the world. Look at our response to Haiti and what happened there. But we have to explain to people what we're doing and how it's successful and the difference that it's made. And we also have to tell people what the real story is. You know, one of the things, again, that President Clinton and Bill Gates talked about is people think we spend all this money of our budget on foreign affairs and assistance to other countries around the world on global health. And when you tell people it's only a quarter of one percent, then they say, oh, well, and what you get for it, then people understand that argument and support it much more. Let me ask you both another question. If I may, two houses of Congress, do you think that the committee structure constituted with its fragmented jurisdiction in a sense with respect to global health is a significant impediment to moving forward? And do you think there'd be a willingness, there's a proposal in the report, as you know, to have a consultative group across the committees to try to bring this together? One, do you think it's a problem? And two, do you think that Congress would be receptive to trying to do something of that sort? I'm going to defer to the center, but would you like me to go ahead? Go ahead, yeah, go ahead. I think that there is, I think we have chairs of foreign affairs in the Senate and the House who are certainly interested in reform in the area of global health and, again, foreign assistance reform more generally. There are different areas of jurisdiction, and I think that we've just got to get about the business of that reform. I'm confident that because it's been, it's a demonstrated priority for the leadership in both houses in this area that they'd be open to it. I think I can speak confidently as a member of the House that Chairman Berman has been convening us across party lines to discuss these very issues. So I'm confident that Senator Kerry and other chairs would be, as of meanwhile, wonderfully. Well, I'm newer to the Senate, so maybe. And our rules are a little more obstructionist. I've heard this. Yes. No. As somebody who's been trying to see how we can get rid of the filibuster, I find this challenging. And committee jurisdiction issues are very difficult to change, but I think the point and the point that's in the report that's important is what you talked about and what the report talks about, and that is coordinating our efforts better. And I don't care if we do it through some sort of an official group or we do it because we have relationships with committee chairs and ranking members, but the point is to do it in a way that we're not overlapping and that we're being as efficient and as effective as possible. Can I make a quick follow-up? I mean, I just want to again praise the report and the efforts behind the report because it can provide an impetus for that in-gathering that it calls for. And I think that sometimes leaders in Congress need some leadership I think the report is offering that. They may need it. They don't always take it, but any of it. Spoken like an executive, you know. No. I remember when I was a treasurer. I used to try to do that, but it didn't always work. Let me turn the national arena for a moment because the last panel sort of wound up on that a little bit with the spaghetti chart, one thing and another. Tom, you're one of our nation's great diplomats. Is there an ability, do you think, globally to bring greater coordination to these efforts or spaghetti charts, just a fact of life that we're not going to do much about? Yeah, Bob, I think there is. I think the report is well taken. You point out first that internally we need better coordination. My own view is that this administration is less afflicted with the turf disease and more willing to cooperate on a whole-of-government basis than many of its predecessors, including where you and I work. I think that this is an improvement. One has to take advantage of that. And my sense is that for policy coordination there's no substance for the White House. That's a job that has to drive this. So the suggestions of an interagency committee led at the White House by somebody senior, somebody like Gail Smith over here, would be ideal. And secondly, that state can help on the coordination side to keep the White House at the policy level and not have it sort of mire itself. We can put it this way in operations. Interestingly enough, overseas, the one whole-of-government thing that works most of the time is the ambassador and the embassy. And ambassadors have a unique opportunity to be a whole-of-government people. And they have a unique opportunity to bring their people together. And they should be doing this around poverty reduction and health and other things. Internationally, it's much harder. The spaghetti chart represents not so much ideal decisions on the part of the recipient country as we have heard in positions on the part of the donor community. And so we have to go for the moat in our own eye or the beam. And we have to work that hard. I think, finally, I have argued for the last 18 months that we need to take advantage of the bipartisan commitment to global health represented in PEPFAR and its continuation in the $63 billion Obama six-year program and go to the UN this autumn and there will be a summit on millennium development goals. And here the critical drivers are our commitments to food and water and health, all inextricably linked. And to use that as a way to bring the international community along, first with meeting their money commitment, something we have not been very good at. Health is a standout. And we have to find a way to pull that along. And then secondly, to begin this process, which we heard about in the last report, of looking at not only what do we do after the goals, but how we take the shortfalls and the present goals in the direction of success, if I could put it that way. These are all great opportunities and serious challenges and almost every one of them could be driven by and revolves around the health question in a central way. Do I have time for one more question? I have my disciplinary and I'm not sure we do. Okay. Let me wind up with a final question. By the way, millennium development goals are interesting, Tom. I first heard about them. I didn't even know what they were when I was a treasurer. I'll bet you there isn't one in 100 Americans who knows what they are. And I don't say we're ever going to coalesce support politically if people don't know about that. I think everybody in this room does, so we don't have to explain. Yeah, but this is not all of America. No, I wouldn't plan to explain them. I'm just saying it's lack of public information. My final question, how do we, actually from the outside internet interaction with the conference, how do we get recipient countries to take greater ownership of this process since in the final analysis it's only going to work if the recipient countries take ownership? And I think both Congressman and Tom, at least I'm told, have views on that. Senator, you may as well. Congressman, why don't you start? Well, you know, this issue came out very starkly when we were in Kenya and the Kenyan government, I believe, is making good efforts toward the issues of global health, HIV, AIDS, things like that. But the fact is, without PEPFAR funds, they simply could not take care of the needs of their population. And one of the points I made when we were gathered together in the hotel gathering much like this is, you know, what are you guys going to do? Because the operative word in PEPFAR is President's Emergency Program. It's not a permanent aid program. It's designed to effect a acute problem at an acute time. And so I offered that challenge to them. And as a matter of fact, the Kenyan's response, I think, was positive, which is that we know that this is not a permanent program. We're going to have to step up. And they themselves were debating within, among themselves, on what the government's commitment to health expenditures is going to be. So I think one of the best things we can do is provoke a conversation within government to say, how are we going to step up? How are we going to reorganize our budget to make sure we're meeting these health challenges? Bob, three or four things. I think that one of the first things is attitudinal. We ought to be listening. We don't do that very well. Secondly, I think it's extremely important to encourage on their side to simplify and delegate responsibilities so that we have single points of contact. One stop shopping, if I could put it that way. Thirdly, the huge problem. Get the donor community to reduce and standardize and simplify strictures what have become known in the AIDS business as barnacles. Thirdly, help them look at what works in other places. Lessons about functions, activities, and organizations that have been successful. And fourthly, target programs to them to help them acquire skills and knowledge in places where there are gaps. So that in fact we can empower them more and not try to fill all the gaps by the elephants from the outside. And that's not a political comment. I think that's a really important point. You know, we had a hearing not too long ago on Haiti and what comes next in Haiti. And one of the points that was made is that one of the challenges that they faced has been because it's been a place where so many people from outside have come in to provide assistance. That there was never the kind of empowerment and engagement of people in the country to make decisions and to run programs. And that is a critical part of what we've got to do. And I thought the report's point about making sure that we have partners who we can work with is a very important one. You know, we all want to do as much good as we can around the world whether it comes to global health or anything else. But the reality is we have limited funds and we have to pick and choose where we can be most effective for the dollars that we spend. And spending those in places where we have real partners on the ground is very important. Again, it's another point that President Clinton and Bill Gates made is that this is an opportunity for us to help build local governance structures. And we need to be careful about partnering in a way that's going to allow that to happen. How am I now? We're okay? Stop or go on? No, I'm happy to go on. Just mix signal there. No, I didn't know what my disciplinarian was telling me to do. We thank you all. It was very nice to be with you. Thank you.